WHY KEGELS DON’T WORK

byChristine KentonApril 8, 2009

The concept that prolapse and incontinence can be improved by doing ‘reps’ of classic pelvic floor contractions is anatomically false.

Arnold Kegel, a gynecologist practicing in the middle of the 20th century, was the first to place women on their backs and instruct them to contract their pubococcygeus muscles around his fingers. Kegel also developed the perineometer to measure the strength of pelvic floor contractions.

Today there is a virtual army of physical therapists who specialize in women’s pelvic floor ‘strength training’. The basis of this therapy is placing women on their backs and inserting fingers into their vagina to measure pubococcygeous muscle strength, a measurement often quantified by a modern version of Kegel’s perineometer.

Many PTs have added “core strengthening” exercises to their regimen, all of which have been borrowed from yoga and Pilates. These exercise systems compliment each other, because contracting the abdominal muscles leads to a coinciding contraction of the pelvic floor. Women on their backs pulling navel to spine while maximizing pelvic floor contractions constitute the core of most physical therapy programs.

One would think that the massive population of women who are onto their third or fourth or fifth surgeries for prolapse might get a little edgy when told by their doctor or PT to just “Do your Kegels” to avoid further problems. Sadly, they don’t get angry, but ever more resigned to the fact that they must be defective and pelvic floor dysfunction hard-wired into their genes. If Kegels worked to prevent or reverse even a small percentage of prolapse we would know about it after all these decades of women Kegeling themselves silly. The reality is they don’t work at all.

The reason Kegels are useless is because the concept of strengthening a “hole” at the bottom of a “floor” is anatomically inaccurate. There is no hole and there is no floor. There is only a flattened tube at the back of the body that is slowly turned inside out over time because of postural and lifestyle factors that compromise the natural pelvic organ support system.

“Kegeling” pulls the tailbone under and disrupts the natural pelvic organ support and urinary continence systems. “Kegel” is a concept that was based on an erroneous model of female anatomy, which viewed the pelvis as a “bowl” with a “floor” that must be “strengthened”. Not only is the entire anatomical concept wrong, but what has flowed from such profound error in judgment has cost women immeasurably in terms of time, expense, and suffering.

Each time we breathe in, the muscular diaphragm underneath our lungs pushes all our abdominal and pelvic organs down and forward. This means that the bladder and uterus are pushed into the rounded lower belly where they are pinned into position by the forces of intraabdominal pressure. The bladder, uterus, and sigmoid colon, which is contiguous with the rectum, are positioned right behind the lower abdominal wall and at right angles to the pelvic outlet at the back of the body. In this way they are protected from the forces of internal pressure.

The only role the thin, sinewy pelvic diaphragm plays in keeping the organs well-positioned is by stabilizing intraabdominal pressure. The pelvic “floor” functions like a trampoline or drum skin to rebound pressure. Therefore, tautness of the muscles is a much more appropriate concept than “strength”.

That tautness is obtained by stretching the pelvic diaphragm to its greatest dimensions, which is accomplished when the body is held in natural, upright, weight-bearing posture – whether seated or standing. If the abdominal wall is not pulled in, the breath can work to push the organs into the hollow of the lower belly where they are safe from the forces of intraabdominal pressure. When the pelvic diaphragm is elongated is this way, the urinary continence system is also supported. Sitting with the lumbar curve fully in place and then contracting the pelvic diaphragm strengthens the tiny musculature surrounding the urethra. However, there is plenty of “tonic” action happening in those structures even without consciously tightening them. I would argue that working and living in natural female postures supplies the urinary tract with enough muscular activity that the concept of “Kegeling” is made obsolete.

Strengthening the vaginal sphincter muscles does enhance sexual intercourse and orgasm. Therefore, this is one logical reason for engaging is this exercise. How better to “practice” than during actual sexual activity?

Sadly, the commonly held misconception of female anatomy has given rise to an entire industry of vaginal weights and exercisers, which women continue to buy. It has also resulted in a ubiquitous medical practice that amounts to little more than a waste of time for women. A realignment of posture and strengthening the true female core returns women to their natural pelvic organ support system and helps them avoid dangerous and debilitating surgery. It is time the concept of “Kegel” becomes known for what it truly is: exercise to enhance human sexuality.

I just had a pessary placed,,very painful the first day,,still uncomfortable on day 3,,however is helping relieve pain upon urination..My cystacele is stage3..rectocyle stage 1 or 2..a urinary tract infection 6 weeks ago caused my bladder to really buldge and even after being on ABTS twice was still having pain in my urethra constantly…Ive never had urgency before just stress incontinence. I now have both. Can I do the exersizes with the pessary in ? Im getting a bit desparate and of course my GYN is suggesting surgery with the urethral mesh..He says he hasnt had any problems with them ???? Im confused and very skeptical …thank you

Hi, tmr,
Submitted by clavicula on October 31, 2009 – 2:01pm.
I have to tell you, I have stopped doing Kegels altogether months ago (sometimes in the summer) and I just kept and kept feeling better without them. I usually “feel” my urethrocele around period time and ovulation, that is it. Oh, and when I am overdoing my tasks.
I think Kegels helped my “wobbly” urethra to stabilize a bit (not 100% but after 3 births in 3 years that was not my expectation), and my light PP SUI to disappear, that is it.

urethrocele & cross legged kegel
Submitted by tmr00 on October 30, 2009 – 9:05am.
Liv,
Curious about your comment that doing a traditional kegel cross legged pushes your urethrocele further inside you. Curious because I am suffering from multiple prolapse in stage 1 but the urethrocele seems to be the one that bothers me and I would like to “pull in”. It is probably the only one I actually feel at the vaginal opening most of the time.

Kegels opinion
Submitted by clavicula on May 1, 2009 – 10:39pm.
Thanks Christine and everyone for the further clarification. I had to ease up on Kegels, because these excercises (more in a row) were irritating my urethrocele, I guess.
I use them during the day though. I realize it feels good when I stand up, get into posture, I make a strong pelvic floor contraction and feel just better stabilized (maybe it is only in my head, teeehhee).
I just have found and started to practice Nauli. I can prevent the ‘air fills my vagina’ phenomenon with a strong pelvic floor contraction along the ab vacuum.

And one more thing. Besides its irritation factor, if I do Kegels crosslegged, it pushes my urethrocele further inside me. I guess that is b/c the UC is right at the vaginal opening. But anyone please correct me if it is wrong…
Liv

Questions
Submitted by tinyshinythings on April 13, 2009 – 2:03am.
Very interesting ladies, as always. Thank you. I guess I’m too passive in the face of mecial professionals. Maybe it’s a British thing. We do tent to eat horrible meals out and then when the waiter asks if everyhting was okay we say – fine thanks. Generalising I know. Apologies to my Briitish sisters who are well able to handle themselves.

the world is flat
Submitted by granolamom on April 12, 2009 – 9:09pm.
your words resonate with me christine.
when everyone chooses to believe that the world is flat, there is little motivation to listen to the few independant souls who bring evidence that it is round.
when more and more of us sail to the edge and fail to fall off, this idea’s time will come. until then we have to keep encouraging our sisters to seek the truth, because the OBGYN maps simply do not show the way.

and regarding weights for kegels, these are used to provide resistance. its like strapping a two pound weight on your ankles when you walk.
theoretically, one way to strengthen a muscle is to work it against resistance. and that works, its bulks up muscle and enables the muscle to work against greater resistence. it does NOT guarantee better function. certainly not when we’re talking about kegels and prolapse.

finding out more
Submitted by Christine on April 12, 2009 – 11:42am.
I’m going to challenge Louise (one of my favorite sparring partners!) that she is letting gynecology off the hook a bit with her comments below. I see no harm in getting as many opinions as you feel the need – if the opinions are grounded in a correct anatomical framework. The problem is, there is no overarching “systems theory” from which the medical system can teach the sequelae of prolapse to women. No one is saying, “Sally, you have an ‘anterior prolapse’. This is what we call prolapse that is very low on the anterior wall and which involves the urethra. The enlarged circumference of your urethral opening is simply an indication of the increased pressure that is moving through your system because your organs are displaced.”

Not only does the diagnostic framework need to be accurate, but the prognostic framework should be equally so. And we all know it is not. Nowhere does ob/gyn/urogyn offer Anything but pessaries, PT (kegels), surgery, and “Do nothing.” We are all taught prolapse will only get worse and that surgery is the only ultimate cure. Nowhere in medicine (except for the occasional, honest M.D. – usually a GP) are we taught that it is virtually impossible for “pelvic floor” surgery to actually cure, because it is based on anatomical misconception.

The same could be said for so many other maladies. And there are not an infinite number of things that can go wrong with the female pelvis. Gynecology’s shining merit has been in identifying all of the disease processes known to occur. The rarest of rare disorders have names and often known etiologies and treatments. Gynecology’s failure has been in the ways in which common disorders of the female pelvis are treated.

The gyn “Standard of Care” is such an amorphous, ambiguous concept that one has to wonder, Does it hinge on what is truly good for women, or on how lucrative it is? Take uterine polyps, for instance. There are many reputable sources that state uterine polyps are almost always benign and should be left alone. Yet, they are taken out as a matter of course. Which is it? Does the procedure of dilating the cervix and removing the polyps carry any risk ? Which is it? Where is the Standard of Care?

I would like for there to be a planetary women’s health organization that sets a True Standard of Care for all common disorders of the female pelvis. First, however, we must develop a new science to take the place of what has passed for medical science – small studies funded by pharmaceutical companies (even at Universities!) that do not measure all variables (like nutrition and the environment) nor follow their subjects over a broad span of time. Doctors themselves should take up this responsibility, but alas, absolute power corrupts absolutely.

Find out more
Submitted by louiseds on April 12, 2009 – 7:26am.
Hi Sally

You might find out something you didn’t know, or you might not. The one thing that gynos have in their favour is that they see a lot of women’s genitals, so if they examine you properly, they can tell you what is normal and what is not. The problem is that sometimes they say they know what the problem is, when they are just having a bit of a guess.

When you look at all the things we women have go wrong with our pelvic area, you know, Women’s Problems, it is no wonder that doctors don’t always get it right. Most of the symptoms we experience are not life threatening. They just hurt, or feel funny, or make us feel ‘not good’.

They more you can find out from professionals the better. Then you start to understand your body better, and lose the fear of your body and what might happen.

Traitional kegals
Submitted by tinyshinythings on April 12, 2009 – 2:03am.
I know what you mean Lousie. There is definately an element of tucking under. Trying to adapt them in line with what I’ve read here until the video arrives. Am pleased to say I am feeling much better (in no small part due to the emotional support I’ve found here )and feel like a bit of a fruad now. It would seem the majority of my symptoms were down to the vaginal oestrogen (now stopped) which didn’t agree with me. Back to just Aloe Vera gel and vaseline and things have greaty calmed down.

I’ve actually decided that my rectocele is not the culpit at all. My urethra seems very prominent and the hole at the end very large. I’m off to see the FIFTH medical wallah this week. Was going to cancel as they all just say prolapse and walk away but have decided to give this doc my urethra theory and see if she can come up with anything new.
Sally

Traditional Kegels
Submitted by louiseds on April 10, 2009 – 8:07am.
Hi Tiny
Mmm, you maybe right. I don’t Kegel a lot, and I don’t really read a lot about them either. It just occurred to be that in doing a Kegel I am squeezing in, (up) and forward, cos my navel is way out front of my body in WW posture. Maybe I need to go back and read Christine’s instructions again! 😉

I thought that’s what a traditional kegal was? Don’t mean to be rude or dismissive. I realy want to learn So hard with email to express yourself properly. I understand about not lying down to do it, as traditionally taught but I thought it was all about the elevator thing. Imaginging an elevator rising all the way from your cervix to your naval and then slowley releasing. Many thanks

How to
Submitted by tinyshinythings on April 9, 2009 – 2:14am.
Please, I’m still not sure that I am correctly contracting my pelvic diaphram. I understand that it is not a pulling up motion or a belly button to spine motion. Can you explain to me in other words? Many thanks. Sally

intestines as counterweight
Submitted by Christine on April 8, 2009 – 8:52pm.
Interesting ideas, Louise and Alemama. I also see the intestines as a marvelous counterweight to the buttocks, keeping abdominal contents weighted toward the front. I’ve mentioned this before, but I believe working with the intestines is going to prove vital for helping post-hysterectomy women stabilize prolapse. The uterus is primary in keeping the pelvic interior pulled toward the front, but in the absence of a uterus, the counterweight is going to have to come from the guts. I’m working with various breathing strategies to open up the belly and reposition the intestines.

I’ve been thinking
Submitted by alemama on April 8, 2009 – 8:43pm.
and one thing I have noticed is that there seems to be little understanding of rectoceles and why good or bad days happen. My understanding of digestion is minimal but I think we all keep some waste in our bodies at all times. So I am starting to think that a good rectocele day could be caused by the descending colon being pulled up by a filling intestine sort of higher up in the abdomen.

I also thing that the round and round nature of the intestines, held in place by the fascia surrounding them, and only coming downwards at the last minute, also has a role in preventing prolapse. It is like trying to stuff a ball of wool down the plughole of a bathtub. There is no way you can do it. If you unravel it and feed the end into the tub with the water running, the wool will be dragged down the plughole, yard by yard. The fact that the descending colon starts at the top is another protective mechanism because it will naturally drag the rest of the intestines down on top of itself and pin itself in position if straining occurs. This is all generally speaking, of course.

Once again, the aim of vacuum or inversion exercises is to reposition all the organs if possible. I think this is the secret to managing rectocele, keeping the ball of wool wound up.